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Hernia Surgery - Complete Surgical Case Guide

Sources: Bailey & Love's Short Practice of Surgery 28th Ed, Schwartz's Principles of Surgery 11th Ed, Maingot's Abdominal Operations, Fischer's Mastery of Surgery 8th Ed, Sabiston Textbook of Surgery

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1. DEFINITION & BASIC PRINCIPLES

• A defect in the abdominal wall (fascia, muscle, or both)
• Content - tissue forced outwards through that defect (omentum, bowel, fat)

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2. CLASSIFICATION OF HERNIAS

By Location

By Complexity (Clinical Classification)

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3. ANATOMY (The Foundation of Safe Surgery)

• Anterior wall: External oblique aponeurosis
• Posterior wall: Transversalis fascia
• Roof: Conjoint tendon (fusion of internal oblique + transversus abdominis)
• Floor: Inguinal (Poupart's) ligament

• Deep (internal) inguinal ring: Defect in transversalis fascia, midway between ASIS and pubic tubercle
• Superficial (external) inguinal ring: Defect in external oblique aponeurosis
• Inferior epigastric vessels: Lie just medial to the deep ring - this is the key landmark separating direct (medial) from indirect (lateral) hernias
• Cooper's (pectineal) ligament: Fused to periosteum of pubic tubercle; used in repair
• Iliopubic tract: Aponeurotic band, forms inferior margin of internal ring

• Medially: Lateral border of rectus abdominis
• Superolaterally: Inferior epigastric vessels
• Inferiorly: Inguinal ligament

• Triangle of doom: Between the vas deferens and testicular vessels - contains the external iliac artery and vein; never staple here
• Triangle of pain: Lateral to testicular vessels - contains the femoral branch of genitofemoral nerve and lateral femoral cutaneous nerve; stapling causes chronic neuralgia

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4. PATHOPHYSIOLOGY & RISK FACTORS

Indirect Inguinal Hernia

Direct Inguinal Hernia

• Age-related collagen changes (decreased type I : type III ratio)
• Chronic raised intra-abdominal pressure

Risk Factors for All Hernias

• Chronic cough / COPD
• Constipation, straining, prostatism
• Heavy lifting, physical exertion
• Family history (8x lifetime risk if positive)
• Positive family history
• Connective tissue disorders (Ehlers-Danlos, Marfan's, osteogenesis imperfecta)
• Ascites
• Previous lower abdominal incisions
• Cigarette smoking
• Collagen synthesis defects (decreased type I collagen)

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5. CLINICAL PRESENTATION & EXAMINATION

History

• Lump in groin, umbilical region, or at scar site
• Usually painless but may cause aching or heaviness
• Sharp, intermittent pain = tissue pinching at neck (urgent concern)
• Severe pain = possible strangulation (EMERGENCY)
• Ask: Does it reduce spontaneously? Bowel obstruction symptoms?

Examination Steps

1. Examine supine first, then standing (hernias enlarge on standing)
2. Ask patient to cough or perform Valsalva to demonstrate hernia
3. Check for expansile cough impulse (absent if neck is tight = irreducible/femoral)
4. Attempt to reduce the hernia
5. Check if hernia is controlled by pressure at deep inguinal ring:
   • Controlled = indirect/lateral
   • Not controlled = direct/medial
6. ALWAYS examine the opposite side - occult contralateral hernias present in up to 20% of patients

Red Flags

• Overlying skin cellulitis = strangulating hernia; treat as emergency
• Absent cough impulse in firm groin swelling = likely femoral hernia (often misdiagnosed as lymph node)
• No upper limit to scrotal swelling = large inguinal hernia, not a hydrocele

Investigations

• Most cases: Clinical diagnosis only, no investigations needed
• Uncertainty: Ultrasound (first-line), CT scan
• Emergency/bowel obstruction: Plain erect AXR + CT (detects obstructing hernia; excludes malignancy)

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6. INDIRECT vs. DIRECT INGUINAL HERNIA - COMPARISON

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7. SURGICAL REPAIR - OPTIONS AND TECHNIQUES

Operations for Inguinal Hernia (Bailey & Love)

A. Open Suture Repairs (Tissue Repairs - no mesh)

• Herniotomy only: Ligation of sac at deep ring; for children/young adults with indirect hernia
• Bassini repair: Suture of conjoint tendon to inguinal ligament behind spermatic cord
• Shouldice repair: 4-layer imbrication of transversalis fascia + conjoint tendon; best tissue repair, <1% recurrence at expert centres
• Desarda repair: Uses a strip of external oblique for reinforcement (tissue)
• Maloney darn: Lattice of sutures across the posterior wall

B. Open Mesh Repairs (GOLD STANDARD for elective cases)

• Lichtenstein "tension-free" repair: Flat polypropylene mesh placed onlay over posterior wall of inguinal canal, secured with sutures. Mesh wraps around spermatic cord. Simple, reproducible, low recurrence (<5%), local anaesthesia possible. Most widely performed worldwide.
• Mesh plugs and hernia systems: No longer recommended (higher chronic pain rates)

C. Open Preperitoneal Repairs

• Stoppa repair: Large bilateral mesh placed in preperitoneal space via midline incision; for recurrent or bilateral hernias
• Transinguinal preperitoneal (TIPP)

D. Laparoscopic / Robot-Assisted Repairs

• Laparoscopic: Less postoperative pain, faster return to activity, better for bilateral and recurrent hernias, longer learning curve
• Open (Lichtenstein): Simpler, can be done under local anaesthesia, shorter learning curve
• Recurrence rates are equivalent between mesh repairs (open vs. laparoscopic) when properly performed

Operations for Femoral Hernia

1. Low approach (Lockwood): Through groin, simple, local anaesthesia; not if bowel resection needed
2. High approach (McEvedy): Vertical incision, via preperitoneal route; allows bowel resection; preferred for emergency/strangulation
3. Inguinal approach (Lotheissen): Through inguinal canal floor; rarely used now
4. Laparoscopic (TEP/TAPP): Suitable for elective cases

Operations for Other Hernia Types

• Small defects (<3 cm): Mayo repair (overlapping fascia, "vest over pants")
• Larger defects: Mesh repair (onlay or sublay); lower recurrence
• Children: Observe until age 3-4 (80% close spontaneously); operate if persistent

• Primary closure: Only for very small defects
• Open mesh repair (component separation for large defects): Sublay (retrorectus) placement preferred
• Laparoscopic IPOM (intraperitoneal onlay mesh): Requires anti-adhesion mesh
• Robotic retromuscular repair: Gaining popularity

• Sliding (type I): Medical management (PPIs); surgery (laparoscopic Nissen fundoplication) if refractory GORD
• Rolling/paraesophageal (type II/III): Surgical repair due to risk of gastric volvulus; laparoscopic with mesh hiatoplasty

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8. EMERGENCY HERNIA SURGERY

• Time is critical when bowel ischaemia is suspected
• Open or laparoscopic depending on surgeon skill and local facilities
• ~20% require bowel resection - may need conversion to midline laparotomy
• Mesh can still be used in most cases if covered by prophylactic antibiotics, unless there is gross contamination/frank perforation
• Femoral hernias: ALL should be repaired urgently (no such thing as a "watchful waiting" approach - femoral hernias strangulate easily due to rigid, bony canal walls)

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9. COMPLICATIONS OF HERNIA SURGERY

Immediate (within 24 hours)

• Haematoma/bleeding: From subcutaneous vessels or, rarely, inferior epigastric/iliac vessels
• Urinary retention: Common in elderly males; may need catheterisation
• Femoral nerve block: From local anaesthetic spread; resolves spontaneously

Early (1st week)

• Pain, bruising, swelling: Expected
• Seroma formation: Fluid collection at dissection site; common after laparoscopic repair (may mimic early recurrence); usually resolves spontaneously; aspirate if large/symptomatic
• Wound infection: Less common with modern technique

Late (weeks to years)

• Recurrence: Main benchmark of quality - good centres aim for <5% at 5 years; mesh repairs have lower recurrence than suture repairs
• Chronic groin pain (inguinodynia): Up to 10-12% report chronic pain; caused by nerve entrapment (ilioinguinal, iliohypogastric, genitofemoral); managed by physiotherapy, nerve blocks, or neurectomy
• Testicular complications: Ischaemic orchitis (0.5%) → testicular atrophy; injury to vas deferens (rare)
• Mesh complications: Infection, migration, contraction, fistula formation (uncommon with modern lightweight meshes)
• Visceral injury: Bladder (direct hernia sac), bowel (laparoscopic), ureter

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10. SPECIAL/RARE HERNIAS

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11. HERNIA IN SPECIAL POPULATIONS

• Inguinal hernias are almost always indirect (congenital PPV)
• Herniotomy alone (sac ligation) without repair of posterior wall is sufficient
• Contralateral exploration is controversial but considered in very young/premature infants

• Indirect inguinal hernias still occur but femoral hernias are proportionally much more common
• Round ligament is at risk during repair

• Watchful waiting is acceptable for asymptomatic inguinal hernias in men (AHS/EHS guidelines)
• Local anaesthesia for Lichtenstein repair is excellent for high-risk patients
• Femoral hernias should NEVER be managed conservatively

• Approach the repair from the opposite side to previous surgery (anterior recurrence → posterior/laparoscopic approach, and vice versa)
• Consider Stoppa repair for multiple recurrences

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Summary: Key Surgical Mnemonics

• Indirect = "I" goes In through deep ring (Lateral)
• Direct = "D" goes Directly through weak posterior wall (Medial)

• Medially: Lacunar ligament
• Anteriorly: Inguinal ligament
• Laterally: Femoral vein
• Posteriorly: Pectineal (Cooper's) ligament

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